Sudden inability to talk

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My mother is 66 years old. She was diagnosed last month with PD. She also has Essential Tremor and was diagnosed with that in 2001. As far as the PD diagnosis goes she was referred to a movement disorder neurologist when she presented with a resting tremor in her right hand. So far that has been the most pronounced motor symptom she has. She was placed on Azilect and Amantadine. These medications made her nearly catatonic at times as well as exaserbated PD symptoms she didn't even have, or at least weren't noticeable up to that point. She was weaned off the Azilect over a 5 day period and the Amantadine dosage was cut in half. She continued to have terrible side effects and her hands, legs and feet began swelling. The doctor had her stop the Amantadine a week ago yesterday (Wed). Her symptoms have improved and she was back to her old self, minus the resting tremor.

Last evening I was at her house for about 2 hours. We talked and laughed and the evening was a typical one for her (she lives next door to us). I was about to leave when she asked me if I needed her coat to walk back home. I told her no thank you and she replied with slurred, garbled, inaudible, speech that was somewhat hard to hear. I thought she was playing a joke on me until I saw the horrified, scared look on her face. I walked her to the couch and called my husband who is a first responder. He checked her for signs of a stroke and she didn't have any except the sudden slurred speech and inability to communicate well. We decided to take her to the ER. Long story short, they did a CT scan and it was negative. So they attributed this to the PD and started her on a low dose of Sinemet and sent her home. Her speech has not improved over the past 6 hours.

My question is this: Is it common for PD patients who have never had speech problems to suddenly, in mid conversation, have slurred, garbled, inaudible speech? In a matter of a seconds she went from her regular self to a scared, frail person unable to speak. And if this does happen, is this permanent or is there help for it? I'm sorry for going on for so long but I wanted you to have some background knowledge about my mom. Thank you for any help/advice you can offer.

Dina

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It is unusual for someone to have a sudden change in the ability to communicate especially to the extent that they can't talk. It was wise of you to consider that your mother might be having a stroke and it is good that you visited the emergency room for experts to evaluate whether or not it was a stroke. Without seeing your mother in person it is not possible for me to determine why this might have happened but it sounds like it could have been a combination of events.

Speech problems are very common in people with Parkinson disease! It has been reported as high as 89% of people with PD have trouble with their speech or voice. The most common difficulties include reduced vocal loudness, monotone, mumbled articulation and a hoarse or breathy sounding voice. In addition, some individuals have difficulties similar to what you have described - difficulty initiating speech, slower thinking, and occasionally stuttering like behavior. However, these changes are typically gradual. It could be that there was a combination of medications, the impact of PD on muscles for speaking and possibly a contribution from swallowing. People with PD are also at risk for swallowing abnormalities and when someone swallows liquids "the wrong way" (into the air passage instead of the passage to the stomach) the vocal folds can be affected making it difficult to speak temporarily.

At the very least, if your mother has not had exercise based treatment for speech, I would recommend that. The data about the benefits of intensive exercise for people with PD is compelling and may very well help your mother.

Thank you for writing. I would be happy to answer any follow-up questions you might have.

Sincerely,

Leslie Mahler, PhD, CCC-SLP

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Your mother's sudden change in speech was atypical of symptoms observed in persons with Parkinson Disease. And you and your husband did the right thing by taking her to the ER. A word of caution, a CT scan completed within 24-48 hours after a stroke will not show signs of a stroke, particularly if it was a small stroke (bleed). I trust she is now recovered? Is she complaining of a "thick tongue"? Have you noticed that when you ask her to raise her arms over her head, one arm is higher? Does she have a slight droop of her face on one side? If so, these are acute signs of a stroke. If you find her speech is still slurred and she still has a dramatic change in her speech, I suggest you pursue a neurology consult and a repeated CT scan to re-evaluate if she did indeed have a small stroke.

Dr. Celia Bassich

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Before I was diagnosed with PD and after diagnosis, but prior to my taking levodopa, I had episodes of speech distortion exactly as you described your mother's condition. I would be speaking to someone and my words ran together, were garbled, were incoherent plus took my breath away. Although, when I stopped speaking in shock, unlike your mother, my next sentence would come out fine. Which was always a response to my listener's question, "What?" These episodes only happened a few times in about 6 months and since starting the Levodopa has not happened again. All through my 5 years of PD, I have had difficulty with my speech - mostly stuttering, slow formation of words by my lips and lack of air to get full sentences out.

I am 66, I now take 25/100 5x a day and am starting agin to be bothered by not enough air to finish the last word of a sentence and I have my drooling and spitting. When first diagnosed, I complained to my neuro about speech problems and especially choking. I was not tested until after I had started taking levodopa and the meds had pretty much relieved my symptoms at that point in time of my testing so there was not a problem. Now, even on the meds, I loose the breath to get out the last words of the sentence although the intelligible speaking has not started up again. I guess I am due for another swallowing and speech evaluation.

I've tried doing the voice exercises on my own and the noise gets on my nerves and also the tongue exercises for aspiration because my 82 year old mother has to do them and they really wear out the old tongue and both are boring. What we have to go through to keep our parts working Ugh!!! But I know I have to do something before it gets worse.

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Thank you for your inquiry. This is a very insightful and important question.

Although the incidence of speech and swallowing disorders in PD is high, the referral rate to speech-language pathologists for treatment is relatively low. One reason for the low referral rate is that the average age of diagnosis of PD is 60 so the perception is that speech and voice changes are just the result of normal aging. However, a study by Fox & Ramig (1997) demonstrated that people with PD were statistically significantly softer than healthy age-matched controls. Another reason for low referral rate is that people with PD are not always aware of changes in their communication abilities. It is very common for people with PD who speak at a reduced volume to think that family members or caregivers need a hearing aid rather than realizing they are hard to understand. This is an important reason why people with PD can’t do voice and speech exercises on their own. They aren’t able to determine where the appropriate targets are without the skilled intervention of a speech-language pathologist.

Sensorimotor difficulties associated with PD have been recognized for years (Schneider et al., 1987 & Koller, 1984). It is possible that underactivation of cortical motor centers caused by decreased excitation of basal ganglia circuitry has motor and sensory components. Muscle movements are reduced in amplitude and there is a perceptual failure to select the muscle commands for movements of normal amplitude (Berardelli, 1986). A mismatch in the sensory perception of effort relative to the target output has also been identified in people with PD (Ho et al., 1999 & Ramig et al., 1995). When people with PD produce speech at an average normal loudness level their perception is that they are shouting.

Your question is important because any treatment targeted at improving functional communication for people with PD must address the motor and sensorimotor components of the disorder for long term carryover and success.